Surgery Induced Menopause

Menopause represents the permanent cessation of menstrual periods and the loss of fertility due to the loss of ovarian function. It can occur spontaneously (natural menopause) or it can be surgically induced by bilateral oophorectomy. A bilateral oophorectomy is the removal of  both ovaries. 
Menopause usually takes place in women between the ages of 45 and 55. A women is officially in menopause when her periods have stopped for 12 months. Some will begin to experience perimenopausal symptoms years before that time. Symptoms are caused by estrogen levels decreasing. In natural menopause they decrease slowly over time, but what happens when they suddenly drop after surgery?
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What is surgery induced menopause?
Surgical menopause occurs when premenopausal women have their ovaries surgically removed in a procedure called a bilateral oophorectomy. This causes an abrupt menopause, with women often experiencing more severe menopausal symptoms than they would if they were to experience menopause naturally. Surgery induced menopause is most common after a radical hysterectomy that removes the ovaries. Each year about 600,000 women in the United States undergo a hysterectomy.  55% and 80% of these women also have their ovaries removed along with the uterus.

What are the risks?

1. Loss of bone density
2. Low libido
3. Vaginal dryness
4. Infertility
5. Sleep problems
6. Night sweats

Hormonal imbalance can also increase your risk of developing a variety of conditions including heart disease and osteoporosis. Lack of estrogen can decrease bone density and lead to osteoporosis which can cause fractures. 

Common Surgeries Leading to Surgery Induced Menopause:
In most cases, removing the ovaries is a preventive measure against disease. In some cases it’s performed alongside a hysterectomy, a procedure that removes the uterus.

Prophylactic ovary removal:
Prophylactic ovary removal is usually performed by a gynecologist. There have been some cases in which early ovarian cancer has been found during prophylactic ovary removal. This has led many high-risk women to choose to have their ovary removal done by a gynecologic oncologist.

A series of tests are run before prophylactic ovarian removal including:

1. a CA125 blood test to check for a protein that is sometimes elevated when ovarian cancer is present
2. transvaginal ultrasound, a test used to create images of the ovaries
3. CT scan or another type of imaging test

Laparoscopic ovary removal:
Laparoscopic ovary removal is usually performed in the hospital or outpatient surgical center under general anesthesia. In some cases, the surgery can be done using local anesthesia.

Abdominal ovary removal:
Abdominal ovary removal is performed under general anesthesia and generally lasts about 1-2 hours. It may last longer if the surgeon needs to do some further exploration.
Salpingo-oophorectomy is the removal of the fallopian tube (salpingectomy) and ovary (oophorectomy). Elective salpingo-oophorectomy represents the removal of ovaries and fallopian tubes in a woman without indication for this procedure. Risk-reducing salpingo-oophorectomy is defined as the removal of ovaries and fallopian tubes in a woman with hereditary ovarian cancer syndrome.

Indications for salpingo-oophorectomy in low-risk patients:

1. benign ovarian tumors—in cases where cystectomy, enucleation or partial oophorectomy are not feasible; 
2. tubal-ovarian abscess without response to antibiotic treatment;
3. adnexal torsion complicated by necrosis;
4. endometriosis 

Indications for salpingo-oophorectomy in high-risk patients:

1. patients with gynecological malignancies or ovarian metastatic cancer—for staging and treatment;
2. patients with inherited genetic mutations.

Within days or hours of surgery, you will experience the start of side effects.  Unlike natural menopause, which happens gradually, surgical menopause causes a sudden drop in your body’s estrogen level. Side effects can include hot flashes, fatigue, mood swings, and vaginal dryness and irritation. Sexual function is also commonly impacted. But, there can be advantages to these surgeries that outweigh the disadvantages!

​Advantages of Bilateral Salpingo-Oophorectomy (SO):

1. Prevention of Ovarian Cancer
2. Prevention of Breast Cancer
3. Decreasing the Risk of Reintervention after Hysterectomy
4. Surgical menopause can also help to reduce pain from endometriosis. This condition causes uterine tissues to grow outside the uterus. Removing the ovaries can stop or slow estrogen production and reduce pain symptoms.
5. If you have your cervix removed, you'll no longer need to have cervical screening tests. If you do not have your cervix removed, you'll need to continue having regular cervical screening. Removal of the cervix is a hysterectomy. 

Support
Doctors may recommend hormone replacement therapy. HRT counteracts the hormones you’ve lost after surgery. HRT also lowers the risk of developing heart disease and prevents bone density loss and osteoporosis. This is especially important for younger women who have removed their ovaries before natural menopause.
Current international guidelines (6) advise use of MHT for all women who undergo menopause under the age of 45 years provided that they do not have other contraindications to MHT (6).  Treatment should continue until the average age of menopause (51 years) and then be reviewed. Use of MHT will resolve hot flushes and sweats in 80-90% of women, although there is evidence that hot flushes and night sweats as well as vaginal dryness may persist despite MHT use in younger women. There are no specific guidelines on the type of MHT to use but oestrogen only MHT is generally prescribed for those women who have had a hysterectomy (removal of the uterus). Women who retain their uterus should use an oestrogen and progestogen combination preparation.
Support from friends, family, and especially your partner is extremely important and can ease the transition. 

For Hot Flashes:

• Carry a portable fan.
• Drink water.
• Avoid excessively spicy foods.
• Limit alcohol intake.
• Keep your bedroom cool at night.
• Keep a fan at the bedside.

For Stress:

• Maintain a healthy sleep cycle.
• Exercise.
• Meditate.
• Join a support group for pre- and postmenopausal women.

Surgery induced menopause is just one side effect of what could be a life saving surgery for some. It is important to discuss risks with your provider and plan for side effects the same way you would plan for healing after any procedure. 

New Research
A new study is actually suggesting that surgery induced menopause is no worse than natural when it comes to anxiety and depression. In the Study of Women’s Health Across the Nation (SWAN), Dr. Hadine Joffe from the CWMH assessed depression and anxiety symptoms annually for a period of up to 10 years.  During the 10 years of follow-up, 1,793 (90.9%) women reached a natural menopause, 76 (3.9%) reported a hysterectomy with ovarian conservation, and 101 (5.2%) reported a hysterectomy with bilateral oophorectomy. For all groups of women, depression scores decreased from the time of the last menstrual period to the end of the study at about the same rate.Those who experienced surgically induced menopause did not report higher rates of negative feelings than those with natural menopause. While physical symptoms are more intense this study suggests that mentally natural and surgical menopause are the same. 
Surgery induced menopause s caused by big shifts in hormone levels in the body, specifically estrogen levels. Those considering surgery that has menopause as a side effect will want to discuss what to expect with their provider and inquire about hormone replacement therapy. This is another situation where it is great to put plans for support in place beforehand. It can also be helpful to keep your partner informed so they can better support you!

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References:
Finch A, Metcalfe KA, Chiang JK, Elit L, McLaughlin J, Springate C, Demsky R, Murphy J, Rosen B, Narod SA. The impact of prophylactic salpingo-oophorectomy on menopausal symptoms and sexual function in women who carry a BRCA mutation. Gynecol Oncol. 2011;121(1):163-8.
Hickey M, Davis SR, Sturdee DW. Treatment of menopausal symptoms: what shall we do now? Lancet. 2005;366(9483):409-21.
Secoșan, C., Balint, O., Pirtea, L., Grigoraș, D., Bălulescu, L., & Ilina, R. (2019). Surgically Induced Menopause-A Practical Review of Literature. Medicina (Kaunas, Lithuania), 55(8), 482. https://doi.org/10.3390/medicina55080482